Medical therapy to prevent fractures in people with low bone density

25(OH)D: 25-hydroxyvitamin D; BMD: bone mineral density; CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate; GI: gastrointestinal.

* Refer to additional UpToDate content on evaluation of hypercalcemia and hypocalcemia.

¶ Very high risk of fracture: No consensus exists on the definition of very high fracture risk. Examples may include: T-score of ≤–3.0 even in the absence of fractures, T-score of ≤–2.5 plus a fragility fracture, severe or multiple vertebral fractures.

Δ If cost, subcutaneous administration, and long-term safety are not a concern, some experts prefer initial anabolic therapy, recognizing that follow-up therapy with an antiresorptive agent is indicated to maintain gains acquired with an anabolic agent.

◊ Anabolic agents include teriparatide, abaloparatide, romosozumab.

§ Oral bisphosphonates are poorly absorbed and must be taken on an empty stomach first thing in the morning with at least 240 mL (8 oz) of water. After administration, the patient should not have food, drink, medications, or supplements and should remain upright for at least 1 half-hour.